Surviving War, Falling to Suicide

Brain injuries, post-traumatic stress, and depression are as hazardous as any battlefield -- and kill more of our veterans.

The photograph on the front page of the Washington Post showed an Afghanistan veteran with two internally powered prosthetic legs besting his friend — an Army sergeant who works with amputees at the Walter Reed National Military Medical Center — in a playful wrestling match on the floor.

So common are these images today – virile young ex-soldiers and Marines running marathons, prevailing in tests of endurance and strength despite their robotic extremities – that we’ve started to see past their horrific injuries and how they got them.

But how do we replace the spirit of a soldier who lost the will to live somewhere on the road between Ramadi and Fallujah or in the hills of southeastern Afghanistan? Can a damaged brain be reinvented? For every advance the government has made in achieving renewed physical independence for our wounded veterans, it has continued to struggle with ways to restore their mental fitness. The wars overseas might be winding down, but they are coming home with a quiet vengeance.

The more we learned last year about the complexity of mild traumatic brain injury (TBI) in military veterans — and its association with declining cognitive skills, personality changes, memory loss — Post Traumatic Stress Disorder (PTSD), and the emerging suicide epidemic, the more challenging proper diagnosis and treatment have become.

Researchers are now connecting the devastating long-term effects typically associated with boxing injuries — known as chronic traumatic encephalopathy (CTE), a progressive degenerative disease that attacks brain tissue — with repetitive mild concussions experienced by football players and soldiers with blast injuries. CTE might begin with mild symptoms like headaches and memory loss but can lead to depression, angry outbursts, and full-blown dementia. The issue came to a head in the news with the third in a string of NFL concussion-related suicides in May and a massive class action suit alleging that the NFL has known much more about the dangers of play than it has let on.

The most comprehensive study on concussions and CTE to date found that military veterans are experiencing similar rates of CTE similar to those of athletes, probably due to traumatic brain injuries. Published in the December issue of the scientific journal Brain (.pdf), the study found that “for some athletes and war fighters, there may be severe and devastating long-term consequences of repetitive brain trauma that has traditionally been considered only mild.”

This a significant development, but it’s only one piece of the puzzle. In 2009, the Pentagon estimated that up to 360,000 Iraq and Afghanistan War veterans may have suffered brain injury, mostly from blasts caused by improvised explosive devices (IED’s). Not all of these troops suffered repetitive injuries, nor were they necessarily knocked unconscious. Many were instead left feeling “dazed and confused.” Some were comprehensively treated for their concussions, others with less obvious symptoms were sent right back into battle. Countless veterans slipped through a feeble screening process and are now dealing with symptoms that often lead to self-medication and alienation from friends and family.

The military has certainly made strides in attempting to understand the impact of TBI, but there’s still much we don’t know, says Paul Rieckhoff, founder and president of Iraq and Afghanistan Veterans of America (IAVA).

“I think we’re really at the tip of the iceberg when it comes to traumatic brain injury,” he said in an interview with TAC. Rieckhoff noted the hundreds of millions of dollars that have been earmarked for TBI research and educational efforts for Veterans Administration physicians. But diagnosis and treatment remain elusive.

“A lot of the veterans don’t know the symptoms themselves,” he added. “This is something we will be dealing with for decades.”

Making it more difficult, the extent of the damage from mild TBI can’t always be discerned with a ordinary MRI or CAT scans. Some of its symptoms are indistinguishable from those related to PTSD, with which approximately 4,000 new Iraq and Afghanistan veterans are diagnosed each month. Research continues to probe the association of more serious TBI incidents (for instance, when a solider temporarily loses consciousness) with long-term physical and mental problems. A 2008 study found that vets with concussions who had been knocked out suffered from higher rates of poor health afterward but concluded that, according to one synopsis, “one must use caution when attributing health problems to mild traumatic brain injury, because associated PTSD and depression may be the primary problem.”

Suffering an IED blast on the battlefield is most certainly a traumatic event, especially when accompanied by witnessing the death or injury of other service members or civilians. Untangling the physical from the mental damage is never easy.

But doctors and veterans’ advocates feel that they are running out of time, given the skyrocketing rates of suicide among active-duty soldiers and veterans. According to the most recent statistics, Army and Navy suicides are at a record high: 2012 was the worst year for self-inflicted deaths since the military began tracking them in 2001. Secretary of Defense Leon Panetta last summer called the situation an “epidemic” — with approximately 3,000 military suicides on record since 9/11.

The numbers are even worse for veterans — an estimated 18 veterans kill themselves each day, 6,570 a year. That’s comparable, advocates point out, to the approximately 6,600 men and women we’ve lost in Iraq and Afghanistan since 2001.

“We’re a decade behind where we should be,” says Rieckhoff. “If I had to say, it is the most urgent issue we face. The suicide problem is out of control.”

IAVA has counselors on staff who work one-on-one with veterans every day. “It’s not only one thing that leads to suicide, it’s a culmination of a couple of things,” says Rieckhoff. “What you’ve got is a generation of veterans who have shouldered the weight of combat through unprecedented long tours, repeated tours, compounded by a bad economic situation and a really bad bureaucratic situation with the VA” when they finally get home. “There’s a lot of issues piling up.”

Add that to TBI, drug and alcohol abuse, and PTSD, and the brew is toxic. “The suicide numbers have been bad for a long time,” says Rieckhoff. “This is not new.”

On the other hand, officials say the VA’s national suicide hotline has answered 650,000 calls since its launch in 2007 and has made 23,000 “life-saving rescues.” It’s been a “tremendous success,” said Reickhoff, but more veterans need to be aware of it, and long-term problems connected to suicide, like TBI and PTSD, are much bigger than the VA. “From a public health standpoint, the VA can’t do this alone, the Pentagon can’t do this alone.”

“It’s a real challenge, but hopefully the tone is changing … It’s going to be a generational fight,” he said. “We’re going to keep plugging away.”

Soldiers are guinea pigs. The military experiments on them all the time. Agent Orange. Agent Pink. Agent Purple. Each one worse than the last. My father fought in Vietnam, and one day he was heading out on patrol, and this special new toothpaste arrived. You brushed your teeth only once a week with it. But as I said, my dad was heading out on patrol and did not get to use the toothpaste until he got back…but by then those who had used it were suffering from bleeding gums. They bled for almost a month. My dad is now a type 2 diabetic thanks to Agent Orange. He has other issues that cannot be identified by the doctors, but his legs hurt something fierce. Soldiers are guinea pigs. My family has a long history of serving the military, especially in times of war. We are fools.

Great article. My war was Korea. A tour of duty was one year and out. As far as I know, no repeats. It is hard for me to imagine the impact of multiple combat tours. Seems to me that the need for repeated tours is a product of the size of our combat force and the approch we take to fighting wars of the Iraq/Afgan type. The planners need to go back to the drawing board.

One also has to wonder about the quality of VA and Defense Department mental health planning. What did they expect would happen? Another example of Rumsfeld incompetence?

Good article about an overlooked subject, which I have studied myself. If more Americans view these wars as possibly causing at least as many suicides as deaths in combat, they may come away with a less glorified picture of the wars.

@Greg T: Or the consequences of NOT going to war. What is your point? This war is, in my opinion, is not just war. At what point, however, do we as a nations lay down our weapons and just meditate? War is going to happen, no matter, but I’ve forgotten just whose war we are fighting now? Kennedy, LBJ, Clinton (not advertised for main consuption) Bush’s and now Obama’s… more detail in your post would be useful.

Keep in mind that the vast majority of military veterans never see actual combat. I.e., getting shot at or blown up. However almost all uniformed retirees apply for disability simply because it provides a bump in their already generous retirement pay.

Every ache and pain that accompanies simple aging becomes a “service related disability” for retirees under that rubric because there is no downside from applying.

Media sanctified military personnel will game the System as much as anybody else. So the backlog…

Thank you for writing about this hidden cost of the wars that rage on. Actually, it’s not so hidden, considering the impact on families and society at large which, as you point out, will reverberate. In the 80s, I remember when I was in law school and a classmate – a Viet Nam veteran then in his 50s – killed himself. The damage may not manifest itself right away, but the landmines are planted, unseen, and will be exploding around us for decades to come. Not to mention the many thousands of Iraqis and Afghanis who will also suffer, whose names we will never know… we shall reap what we sow… God forgive us.

It’s good to see that the accounting for war is catching up with the realities on the ground. I wonder how so much of this was unknown given the great experiments of WWI and WWII where millions of soldiers around the world faced battle, warfare and it’s aftermath. Were those battlefields so much different than those today?

I guess I don’t know much about war, notwithstanding all my reading on the same. I guess I’ve been blessed.

This never ending nightmare of sending our young men into wars that are totally unnecessary and unproductive has got to stop… but I know it won’t. Just last week my senator, Lindsey Graham/ aka Joe Lieberman’s poodle, said we should stay in Afghanistan “Until we get it right!” Another ten years, senator?

Ms. Vlahos, or someone as capable as she is, should be on every Sunday morning making Americans aware of the misery GW Bush and his neocon chickenhawk warmongers have caused for so many Americans, Iraqis and Afghans. We’re talking millions of lives ruined.

The thought of Bill Kristol and Richard Perle dining in posh DC restaurants, while soldiers, who fought in their concocted wars, live a daily hell makes me, to put it mildly, very angry.